Do you finish notes with the patient in the room? If not, how do you get out on time?

[Trismegistus4]

(I realize this is a residency board, and this question really pertains to "real-world" practice, but I don't know of any other board with so many active and engaged psychiatrists posting. Residents, if you've mastered this art, feel free to respond as well.)

I first encountered the notion that one could finish one's note with the patient in the room in PGY-3 year, on my one day a week of community mental health agency clinic. Before that, it had always seemed like note-writing was a distinct activity one carved out time for. In medical school, I feel we were almost encouraged to write long notes, with a long, narrative HPI, and extreme detail in every section. (Ostensibly, we were taught we needed to learn to do this because it was really the "right" way to document, even though it was obvious at the time that our attendings never wrote such long, detailed notes, so they were teaching us to do it the "right" way while showing by example that no one ever does it the "right" way again in their lives, but I digress.) Even in residency, we always took our time to do our notes. But in that community mental health clinic, the 4-5PM time slot was set aside for supervision, and my supervisor wanted me to have my notes done by the time he signed them, so I learned to do it. That agency was still on paper charts, so, figuring that no one expected much out of a 2-sided 1-page initial visit H&P or 1-sided follow-up anyway, I decided I could get away with chicken scratch handwriting, phrases instead of complete sentences, etc. Then, after residency, I did a few locums assignments, most of which were inpatient, allowing me the flexibility to work at my own pace. I was slow at first, but eventually learned to get done on time... but even that allowed me to treat note-writing as a separate activity from patient-interviewing.

Then last summer I started this outpatient job, which is 8-5, and I think I'm doing something wrong, because today, for the 2nd time this week, I didn't leave the office until 6:30, because after the last patient walked out the door, I still had all these notes to finish. And I know I shouldn't be there that late, because my colleagues at the other office (I'm the only psychiatrist at this location, but I started at another office where there are other psychiatrists) all stroll out the door at 5:05 PM. At first, it wasn't a problem; I was new, so I didn't have many patients, and had huge gaps in my schedule, so I could just finish my notes then. Later, as my schedule began to fill up, it still wasn't a problem at first, because I had a lot of no-shows (presumably because we were working through a huge backlog of referrals, and many of the new patients had probably had the appointment scheduled 6 months prior, and forgotten all about it) so I could just do my notes then. Now, however, on days where all or almost all of my patients show up, I'm realizing I have to choose between 1) finishing notes with the patient in the room, or 2) staying until 6:30 every night.

So, is that what you guys are doing? Finishing notes with the patient in the room? If so, how do you do it? We use Epic, which is the best EMR I've used, but I still have this compulsion, drilled into me in medical school, to have the HPI be something of a narrative. Should I scrap that? I sit there and type while the patient is talking, but because I'm trying to let it be at least something of a conversation, and thus actually make periodic eye contact with them, and because I'm trying to keep up, I make massive numbers of typos, and wind up with random phrases that don't form complete sentences, and out-of-order information. Then, once the appointment is over, I feel the need to clean all that up. Then there's the mental status exam, labs, etc., which are template-based, but still, I need to go over them. Then I also feel the need to write a paragraph-style assessment like we used to do in med school/residency. For a new patient, this can easily take 15 minutes per note. Follow-ups aren't as bad, but I still have to clean up all the typos in the little paragraph of subjective info, and update all the other stuff.

I'm sure we all had the experience in residency of receiving records from some private practice doc and being amazed at how bare-bones the notes were. S: a few short phrases. O: template-based or cut-and-paste. A: no paragraph, just a one-line diagnosis. P: list of meds (or even just "continue meds as is".)

Is that what I need to do? I've seen a couple notes by my colleagues here and they are shorter than mine--particularly the HPI section for a new patient. So, do I need to suck it up, forget all that narrative stuff that makes me feel like I'm actually getting to know the patient, forgo all eye contact so I can type with proper spelling, punctuation, and capitalization while the patient is talking, and just do these bare-bones short-phrases notes?

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[SmallBird]

(I realize this is a residency board, and this question really pertains to "real-world" practice, but I don't know of any other board with so many active and engaged psychiatrists posting. Residents, if you've mastered this art, feel free to respond as well.)

I first encountered the notion that one could finish one's note with the patient in the room in PGY-3 year, on my one day a week of community mental health agency clinic. Before that, it had always seemed like note-writing was a distinct activity one carved out time for. In medical school, I feel we were almost encouraged to write long notes, with a long, narrative HPI, and extreme detail in every section. (Ostensibly, we were taught we needed to learn to do this because it was really the "right" way to document, even though it was obvious at the time that our attendings never wrote such long, detailed notes, so they were teaching us to do it the "right" way while showing by example that no one ever does it the "right" way again in their lives, but I digress.) Even in residency, we always took our time to do our notes. But in that community mental health clinic, the 4-5PM time slot was set aside for supervision, and my supervisor wanted me to have my notes done by the time he signed them, so I learned to do it. That agency was still on paper charts, so, figuring that no one expected much out of a 2-sided 1-page initial visit H&P or 1-sided follow-up anyway, I decided I could get away with chicken scratch handwriting, phrases instead of complete sentences, etc. Then, after residency, I did a few locums assignments, most of which were inpatient, allowing me the flexibility to work at my own pace. I was slow at first, but eventually learned to get done on time... but even that allowed me to treat note-writing as a separate activity from patient-interviewing.

Then last summer I started this outpatient job, which is 8-5, and I think I'm doing something wrong, because today, for the 2nd time this week, I didn't leave the office until 6:30, because after the last patient walked out the door, I still had all these notes to finish. And I know I shouldn't be there that late, because my colleagues at the other office (I'm the only psychiatrist at this location, but I started at another office where there are other psychiatrists) all stroll out the door at 5:05 PM. At first, it wasn't a problem; I was new, so I didn't have many patients, and had huge gaps in my schedule, so I could just finish my notes then. Later, as my schedule began to fill up, it still wasn't a problem at first, because I had a lot of no-shows (presumably because we were working through a huge backlog of referrals, and many of the new patients had probably had the appointment scheduled 6 months prior, and forgotten all about it) so I could just do my notes then. Now, however, on days where all or almost all of my patients show up, I'm realizing I have to choose between 1) finishing notes with the patient in the room, or 2) staying until 6:30 every night.

So, is that what you guys are doing? Finishing notes with the patient in the room? If so, how do you do it? We use Epic, which is the best EMR I've used, but I still have this compulsion, drilled into me in medical school, to have the HPI be something of a narrative. Should I scrap that? I sit there and type while the patient is talking, but because I'm trying to let it be at least something of a conversation, and thus actually make periodic eye contact with them, and because I'm trying to keep up, I make massive numbers of typos, and wind up with random phrases that don't form complete sentences, and out-of-order information. Then, once the appointment is over, I feel the need to clean all that up. Then there's the mental status exam, labs, etc., which are template-based, but still, I need to go over them. Then I also feel the need to write a paragraph-style assessment like we used to do in med school/residency. For a new patient, this can easily take 15 minutes per note. Follow-ups aren't as bad, but I still have to clean up all the typos in the little paragraph of subjective info, and update all the other stuff.

I'm sure we all had the experience in residency of receiving records from some private practice doc and being amazed at how bare-bones the notes were. S: a few short phrases. O: template-based or cut-and-paste. A: no paragraph, just a one-line diagnosis. P: list of meds (or even just "continue meds as is".)

Is that what I need to do? I've seen a couple notes by my colleagues here and they are shorter than mine--particularly the HPI section for a new patient. So, do I need to suck it up, forget all that narrative stuff that makes me feel like I'm actually getting to know the patient, forgo all eye contact so I can type with proper spelling, punctuation, and capitalization while the patient is talking, and just do these bare-bones short-phrases notes?

I never write notes with the patient in the room as I can't build alliance that way (not saying others can't but it's not my style). I think the solution depends on the context? When I've had back to back med checks, I'd see the patient and family (I'm mostly doing child work) for about 12-16 minutes and then right the note in 4 minutes. In Epic if you have a good template set up you can write a good note very quickly. That way you can still see three patients in an hour. Progress notes should be short! This is not simply because we don't have the time, it's better for them to be short and to the point to help focus clinical reasoning and for medico legal purposes.

It can be more challenging for intakes, since a good intake should have full sentences, at least a paragraph for HPI and a few lines for formulation. In my previous clinic we had an hour, so I'd see the patient for 45 minutes and then dictate. In my current clinic we have epic but they give me 75 minutes which is plenty to do both. But even writing an intake in Epic shouldn't take more than 10 minutes if you set the template up well and have a good cognitive schema for what the purpose is of your evaluation and what data you need to include.

One other thought - writing a long narrative in a note doesn't help a patient, or imply that you have a better understanding than someone who wrote a much shorter note. If you simply focus on making sure you do in fact understand the patient, the note becomes easier too. Using your note as the way you organize your understanding is very time consuming, in my opinions.

That's just my two cents anyway!

 

[Armadillos]

Only a resident, but who gains what benefit from you writing a long HPI and paragraph long assessment?

 

[st2205]

Only a resident, but who gains what benefit from you writing a long HPI and paragraph long assessment?

The transference of the ghost of attendings past.

 

[DJspreadsheet]

Only a resident, but who gains what benefit from you writing a long HPI and paragraph long assessment?

I can nearly guarantee, for most, it's fear of liability. There's the sense a long diatribe is evidence that you have done your due diligence. It may be rather pessimistic, but I feel much of what we do is fear of liability.

There are of course those that use their note to prove to the world how brilliant and compassionate they are. But God I hope that goes away after residency.

 

[deleted314290]

I dont type notes with the patient in the room as that is a sure way to ruin rapport. They want to know that their doctor is listening to them and has their undivided attention. I make up for it by writing a short and succinct HPI that covers the billing bases.

I can nearly guarantee, for most, it's fear of liability. There's the sense a long diatribe is evidence that you have done your due diligence. It may be rather pessimistic, but I feel much of what we do is fear of liability.

There are of course those that use their note to prove to the world how brilliant and compassionate they are. But God I hope that goes away after residency.

Whats that saying... the more you write the more rope you give the lawyer to hang you with?

 

[DJspreadsheet]

Whats that saying... the more you write the more rope you give the lawyer to hang you with?

Good point and not something that's ever discussed (if you're going to expend any energy in your documentation, it should be in your A/P). One of the problems with residency, I think. Your mentors are living in la-la land and don't have anything sage to offer for those entering the battleships.

One of our attendings fancies themselves an expert in X pathology (I'm certain our department would agree as to their expertise). This person will wax poetic on management, but this person hasn't followed an outpatient since residency. Every patient interaction I've seen with this person devolves into a total **** show where they rile up every patient they interact with.

 

[birchswing]

This question intrigues me because my psychiatrist is my only doctor who I know to write notes. She writes before I even start talking and through the entire appt. Not sure what she's writing. It's not as if we do therapy, so there's not much to write. She writes by hand. Only she and my dentist are the ones to still use paper records. My PCP and other specialists don't seem to write notes, nor does my therapist, at least not in my view. My very first psychiatrist, back in maybe 1998, used an audio recorder in our session—not for the entire appointment, but he would pause us speaking and then speak into the recorder, very quietly so I didn't really hear what he said. Interesting about the rapport. I once told my psychiatrist I had the sense she didn't like me and was concerned about a lack of likingness (my therapist had told me that you can't effectively be treated by someone who doesn't like you), and she told me she wanted me to feel that way because it keeps me motivated. One of those pearls of wisdom I've tucked away.

 

[Ceke2002]

My Psychiatrist has always written notes during session (pen and paper). He just doesn't like write non stop throughout the session, I've noticed he kind of waits until there's a pause, or a moment where he doesn't need to be as focused on me to quickly jot down a few pertinent points (or whatever it is he's writing). It's not ever like I'm sitting there while he's got his head down the entire session just scrawling words on a page, like 'Oi, sunshine, up here for a sec thanks'. What he does after I've left the appointment I don't know, never bothered to ask.

 

[Jules A]

I dont type notes with the patient in the room as that is a sure way to ruin rapport. They want to know that their doctor is listening to them and has their undivided attention. I make up for it by writing a short and succinct HPI that covers the billing bases.

Whats that saying... the more you write the more rope you give the lawyer to hang you with?

Yeah minimize the pontificating. The OP seems somewhat verbose even here which will likely take a concerted effort to contain but will result in an improvement in efficiency.

I type while the patient is in the room although if for example it derails into tears I briefly stop and redirect to their therapist. I admire those who are able to manage not typing in front of patients and yet finish documentation prior to the next patient. I'm not consistently able to secure enough uninterrupted time at the conclusion of the appointments to do the entire note and don't like to wait until the end of the day. I'm not into working late for free, can't freaking remember what I meant to include and jotting notes as a reminder that will later be added to EMR seems like overkill so I largely type as I go.

 

[splik]

Only a resident, but who gains what benefit from you writing a long HPI and paragraph long assessment?

I dont have time for long HPIs (no point) but a good assessment is paramount.

As a resident notes are like your calling card. I will decide whether you are a good resident based on your documentation. Poor documentation and I will assume you are a poor psychiatrist or at least a lazy psychiatrist.

For psychiatrists in the real world, a good assessment again is how other psychiatrists know if you are any good or not. Your documentation follows the patient. Write poor notes and people will think you are a poor psychiatrist. Furthermore, a clear assessment is helpful to the patient to see how you formulated their problems and plan. It is helpful for future psychiatrists trying to figure out what you did, why you did it, where this dx came from. Poor documentation, and I will assume the previous psychiatrist was wrong about everything and have to start again. The patient will be annoyed about this. For high level complexity billing, it is helpful to have a good assessment for the MDM for level 5 billing. When I am reviewing cases for for possible malpractice, a good assessment will be the difference between me saying there are grounds for a malpractice case or not.

So yeah, I would say that an assessment is important. Also patients tend to blur together. You need to write enough that you remember who the patient was and what you were thinking the next time you see them. Electronic records certainly created overly long unwieldy documentation. But it really doesnt take that long to write a decent assessment and it is beneficial for you, for your colleagues, for patients, for billers, for continuity of care, and to reduce complaints and law suits.

A good assessment is not long. But it isn't one word either.

 

[HarryMTieboutMD]

I dont have time for long HPIs (no point) but a good assessment is paramount.

As a resident notes are like your calling card. I will decide whether you are a good resident based on your documentation. Poor documentation and I will assume you are a poor psychiatrist or at least a lazy psychiatrist.

For psychiatrists in the real world, a good assessment again is how other psychiatrists know if you are any good or not. Your documentation follows the patient. Write poor notes and people will think you are a poor psychiatrist. Furthermore, a clear assessment is helpful to the patient to see how you formulated their problems and plan. It is helpful for future psychiatrists trying to figure out what you did, why you did it, where this dx came from. Poor documentation, and I will assume the previous psychiatrist was wrong about everything and have to start again. The patient will be annoyed about this. For high level complexity billing, it is helpful to have a good assessment for the MDM for level 5 billing. When I am reviewing cases for for possible malpractice, a good assessment will be the difference between me saying there are grounds for a malpractice case or not.

So yeah, I would say that an assessment is important. Also patients tend to blur together. You need to write enough that you remember who the patient was and what you were thinking the next time you see them. Electronic records certainly created overly long unwieldy documentation. But it really doesnt take that long to write a decent assessment and it is beneficial for you, for your colleagues, for patients, for billers, for continuity of care, and to reduce complaints and law suits.

A good assessment is not long. But it isn't one word either.

Agreed in principle but most of the good psychiatrists in the community (non academia but who trained at our program) and some of our attendings write horrible notes with marginal assessments. However, their management is spectacular, and for me those 2 factors (where they trained and management) have best way to judge the quality of the psychiatrist

 

[NickNaylor]

Can't really speak on the writing-notes-with-patient-in-the-room topic (though I hated doing it in medical school) since we haven't done much outpatient work.

On the topic of "long" notes, I will admit that I tend to write lengthy notes. This is for my own benefit than the benefit of anyone else as it helps me get my thoughts together and think about all of the information obtained from the interview. I agree wholeheartedly with @splik's point about assessments, and I think if there's any part of the note that is more voluminous then it should the assessment. Right or wrong, I also see the assessment as an overall litmus test for the quality of the evaluation: a garbage assessment = I don't trust whatever the other psychiatrist diagnosed = I repeat everything. While the other portions of the note are essentially dictation, the assessment is where I get to see how a physician thinks. I appreciate a brief discussion of a differential and why, say, someone is diagnosed with bipolar disorder vs. unipolar depression (if presenting with a depressive episode). If they're started on a non-typical regimen, then some discussion of why is helpful.

The chief of our service actually sent out a "training" module that could best be described as "how to document an assessment and plan." Some of the NPs who work in the psychiatric ED write completely garbage notes that provide zero insight as to why they were given the diagnosis they were given and why they were started on the treatment they were. It makes it difficult when following up on those patients or if they happen to come through the ED again. Thus, I'd prefer longer than shorter notes though, again as @splik said, length is not really the critical thing. I think as long as you're able to get your thought process on paper and justify clearly why it is that you did what you did, your documentation is effective. Length and details aren't necessarily a requirement for that to happen.

 

[smalltownpsych]

I find it helpful to just report objective facts. My opinion is rarely in the record and I find that I tend to disagree with others opinions in their records, anyway. I do about a one page intake and paragraph progress notes. In mutual cases, I prefer when psychiatrist focuses on assessment of symptoms as I will focus more on psychosocial stuff.

 

[WisNeuro]

Just do what I see most often in HPIs from my referring providers, stream of consciousness rambling, with an alarming number of ellipses.

 

[deleted736562]

From a resident's perspective, one thing that irks me are notes with information cherry-picked to justify whatever management decision was taken. I understand this is usually done for legal reasons (protect one's a** basically), but it's not trustable and I think the HPI should run in a more objective manner, which would also necessitate a certain level of detail. Then you'll always be in a race against time. Just wondering what people think about this.

 

[FlowRate]

I'm not in the outpatient stage of things, so I can't help directly with the workflow part of your question. I do work in EPIC part of the time, and I'd recommend getting a good MSE template where each section has a smart list with your most-used descriptors. It takes me <30 seconds to do a MSE on a patient. If there are any relevant/interesting/unusual findings, you can always freetext them.

What I need to do is finally get set up with our dragon licenses... I'm a very fast typist but I think dictating may still be faster.

The chief of our service actually sent out a "training" module that could best be described as "how to document an assessment and plan." Some of the NPs who work in the psychiatric ED write completely garbage notes that provide zero insight as to why they were given the diagnosis they were given and why they were started on the treatment they were. It makes it difficult when following up on those patients or if they happen to come through the ED again. Thus, I'd prefer longer than shorter notes though, again as @splik said, length is not really the critical thing. I think as long as you're able to get your thought process on paper and justify clearly why it is that you did what you did, your documentation is effective. Length and details aren't necessarily a requirement for that to happen.

That reminds me of the psych NP who does consults at the community place where I'm doing medicine. She writes some of the longest notes I've ever seen, but the entire of the note is written in this format:

-give x medication
-remind patient y
-patient has suicidal ideation
-etc. etc.

But over half of the phrases are close to meaningless, not to mention there's no actual narrative assessment, just endless lines of recommendations intermixed with MSE/HPI outside of their respective sections. I keep wondering whether she has some sort of template, because the phrases are often repeated, and if she just cuts out the parts she doesn't want for that particular patient.

 

[Shikima]

Long answer for this question is; sometimes I do. The short answer is; sometimes I do.

You can pick and choose when you're sitting quietly and listening vs being active with multitasking and you're patients know that you are listening to them. They may not like that you're a stenographer now, but they'll get used to it in the modern age of EMR. Besides, you can wrap up the session efficiently by asking if their correct pharmacy is Smith's on Main St.

 

[PistolPete]

Long answer for this question is; sometimes I do. The short answer is; sometimes I do.

You can pick and choose when you're sitting quietly and listening vs being active with multitasking and you're patients know that you are listening to them. They may not like that you're a stenographer now, but they'll get used to it in the modern age of EMR. Besides, you can wrap up the session efficiently by asking if their correct pharmacy is Smith's on Main St.

Ha, I mostly do this. Intermittent typing with intermittent no-typing-face-the-patient-and-talk. It's worked fairly well for me. I usually finish up my note after the patient leaves.

 

[Shikima]

Ha, I mostly do this. Intermittent typing with intermittent no-typing-face-the-patient-and-talk. It's worked fairly well for me. I usually finish up my note after the patient leaves.

This is what I do too. It works well, and my work is done with the last patient of the day. Nothing hanging around and needless hours of charting after they're all gone.

 

[Information Underload]

I haven't been able to get by writing with patients in the room, and thus I often stay later than I would like. I use Dragon Anywhere and dictate the HPIs and assessments for my initial evals on the car ride home (keeping it HIPAA-compliant) and try to finish up the rest of those notes with the patient still in the room. Efficiency is somewhat the bane of my existence, but I do see patients for 40-minute appointments with therapy, and it is just going to kill rapport if I'm trying to type and keep conversation going.

Notes for me function to keep everything right in front of me for follow-ups: who the patient's therapist is, previous medication trials, psychosocial stressors and formulation. Other than that, they cover one legally and justify billing. Drop the psychosocial stuff and gossip. I am awaiting actually having a functioning EMR for outpatient notes, so my note style will likely change in time.

 

[Wilf]

Agreed in principle but most of the good psychiatrists in the community (non academia but who trained at our program) and some of our attendings write horrible notes with marginal assessments. However, their management is spectacular, and for me those 2 factors (where they trained and management) have best way to judge the quality of the psychiatrist

Agree with this. Some of the best psychiatrists I've met have written very short notes, including assessments. In general residency, one of the senior psychiatrists who was quite good would sometimes write something as simple as "patient presents psychotic similar to previous admission, poor medication compliance, and will begin invega sustenna" as their assessment. If cases warranted it, her assessment would include more.
Also, splik, it's a bit early to be saying "as a resident your notes are like your calling card." Weren't you a resident as recently as June? Also, that statement isn't true.

 

[Jules A]

Agree with this. Some of the best psychiatrists I've met have written very short notes, including assessments. In general residency, one of the senior psychiatrists who was quite good would sometimes write something as simple as "patient presents psychotic similar to previous admission, poor medication compliance, and will begin invega sustenna" as their assessment. If cases warranted it, her assessment would include more.
.

This! The best psychiatrist by far who I have had the privilege of working with writes beautifully clear yet succinct notes. I have worked with good and not so good docs who write extremely long notes and personally they lose my attention in both instances. My opinion tends to be the good docs are coming off as rather grandiose and the bad docs are just pathetically trying to justify their convoluted assessment.

 

[AcronymAllergy]

As a psychologist, I often read the entirety of our psychiatrists' notes, and typically find them to be very informative. Length doesn't matter, although I've found it more difficult (but more helpful) to be concise yet complete. However, it does help me immensely when the psychiatrist includes a snippet of their rationale and/or conceptualization of the patient, even if it's "only" a sentence. This helps me save time during my own interview.

 

[JustAGuy]

I would guess it has to do a lot with how fast of a typist you are. If you can type 90+wpm, I don't understand how you couldn't finish your note while the patient is still in the room. I can type pretty fast, write decently long notes, and can count on one hand the number of times I've stayed late in the last year d/t notes.

 

[OldPsychDoc]

I just remember a patient (irritably depressed, but not psychotic) staring down a med student and resident as they typed away during my interview, and growling "What are you two? Stenographers?"

 

[Shikima]

I just remember a patient (irritably depressed, but not psychotic) staring down a med student and resident as they typed away during my interview, and growling "What are you two? Stenographers?"

Pretty much with EMRs. Gov't mandated it.

 

[OldPsychDoc]

Pretty much with EMRs. Gov't mandated it.

Yeah--but the point is that we do our patients and our profession a huge disservice if we're making more eye contact with the screen than the person.

 

[Ceke2002]

I just remember a patient (irritably depressed, but not psychotic) staring down a med student and resident as they typed away during my interview, and growling "What are you two? Stenographers?"

Yeah--but the point is that we do our patients and our profession a huge disservice if we're making more eye contact with the screen than the person.

I have no problem with my Psychiatrist taking pen and paper style notes during session, I don't expect him to be locking eyes with me non stop (actually that would be rather creepy), and it doesn't bother me if he ocassionally glances down to make a few quick notes during natural pauses in the conversation. I doubt I'd feel the same way though if he were typing those same notes as opposed to writing them by hand. Having a Doctor typing in front of me throughout an appointment, with the exception of perhaps a quick, non complicated 5-10 minute GP visit, I imagine would feel incredibly intrusive.

What's wrong with writing notes by hand and then transferring them to electronic form at a later time? Why the mandate that notes have to be electronically recorded at all times? That doesn't really seem to serve the patient's best interests.

 

[birchswing]

What's wrong with writing notes by hand and then transferring them to electronic form at a later time? Why the mandate that notes have to be electronically recorded at all times? That doesn't really seem to serve the patient's best interests.

I would guess it's that it costs more to have a transcriptionist. I don't know exactly what the law/rule was, but something in our Affordable Care Act (ObamaCare) somehow encourages electronic record keeping. It's probably either a financial incentive or something tied to Medicare reimbursements; it must not actually be 100% required because my psychiatrist's office still uses paper records. I don't believe there's anything regulating therapy/progress notes, though (things a therapist or a psychiatrist doing therapy would use for their own purposes to jog their memory, etc.). That might be what your psychiatrist is writing by hand.

 

[Ceke2002]

I would guess it's that it costs more to have a transcriptionist. I don't know exactly what the law/rule was, but something in our Affordable Care Act (ObamaCare) somehow encourages electronic record keeping. It's probably either a financial incentive or something tied to Medicare reimbursements; it must not actually be 100% required because my psychiatrist's office still uses paper records. I don't believe there's anything regulating therapy/progress notes, though (things a therapist or a psychiatrist doing therapy would use for their own purposes to jog their memory, etc.). That might be what your psychiatrist is writing by hand.

The notes he's taking in session I've always assumed are either memory joggers and/or or just an overall impression of the conversation that will probably be converted into more detailed progress notes, from a Psychotherapy point of view, at a later date. The clinic I see him at is paper based in terms of patient records as well, although whether those records are also electronically recorded/stored I don't know. Efficiency is good as well, of course, but efficiency at the cost of patient rapport seems a tad counter-intuitive.

 

[Ceke2002]

This might be useful.

http://www.psychiatrictimes.com/blo...tive-note-writing-primer-psychiatry-residents

 

[hamstergang]

What's wrong with writing notes by hand and then transferring them to electronic form at a later time? Why the mandate that notes have to be electronically recorded at all times? That doesn't really seem to serve the patient's best interests.

I do this, but there are 2 major issues:

1) it takes extra time that no one gets paid for.

2) something bad could happen to the patient between the visit and when the note makes it into the computer. It doesn't look good if you write the note with knowledge of the bad outcome as it could influence what you write.

 

[Shikima]

Yeah--but the point is that we do our patients and our profession a huge disservice if we're making more eye contact with the screen than the person.

Perhaps, but it's not efficient. I would be glad to go back to paper and pen with a script pad. Less nonsense and better quality.
My personal belief that EMR was mandated was to track health care metrics and making physicians responsible for accurate documentation.

 

[Ceke2002]

I do this, but there are 2 major issues:

2) something bad could happen to the patient between the visit and when the note makes it into the computer. It doesn't look good if you write the note with knowledge of the bad outcome as it could influence what you write.

But if you have the note on paper, what's the difference whether it made it into the computer in time? I mean you still have a record of the note, you can still show the note to anyone who needs to see it.

 

[OldPsychDoc]

I do this, but there are 2 major issues:

1) it takes extra time that no one gets paid for.

2) something bad could happen to the patient between the visit and when the note makes it into the computer. It doesn't look good if you write the note with knowledge of the bad outcome as it could influence what you write.

#2 is a strawman...you could say the same thing about surgeons dictating procedure notes: what if the patient crumps in the PAR before you're done dictating? Wouldn't the knowledge of that outcome influence your dictation, assessment of complications, etc?

 

[hamstergang]

But if you have the note on paper, what's the difference whether it made it into the computer in time? I mean you still have a record of the note, you can still show the note to anyone who needs to see it.

Because I didn't think you were talking about a true note, but instead:

The notes he's taking in session I've always assumed are either memory joggers and/or or just an overall impression of the conversation that will probably be converted into more detailed progress notes

#2 is a strawman...you could say the same thing about surgeons dictating procedure notes: what if the patient crumps in the PAR before you're done dictating? Wouldn't the knowledge of that outcome influence your dictation, assessment of complications, etc?

I guess it depends how much later the note is written.

 

[Ceke2002]

Because I didn't think you were talking about a true note, but instead:

Oh, sorry I didn't really express that very well (It's nearly 4 am, it's 78 degrees, and I think my brain has melted) - I meant the difference between clinical notes and the writing up of longer psychotherapy progress type notes.

 

[Bartelby]

#2 is a strawman...you could say the same thing about surgeons dictating procedure notes: what if the patient crumps in the PAR before you're done dictating? Wouldn't the knowledge of that outcome influence your dictation, assessment of complications, etc?

Maybe, but if you see the patient Monday, he commits suicide (and you learn of this) Thursday, and then you write a note with a wonderful risk assessment on Friday I think it will be viewed much more skeptically. In that situation I would prefer good-enough documentation entered before the suicide to a wonderful note entered after.

Still, suicides are quite rare, and if you have lots of good care documented in the chart in the weeks and months before the event in question that would still count for a lot and might still support that you met standard of care during the encounter in question. So it's kind of a personal call. For me, I prefer having notes entered within 24 hours for a variety of reasons, and I try to keep them succinct.

 

[OldPsychDoc]

Maybe, but if you see the patient Monday, he commits suicide (and you learn of this) Thursday, and then you write a note with a wonderful risk assessment on Friday I think it will be viewed much more skeptically. In that situation I would prefer good-enough documentation entered before the suicide to a wonderful note entered after.

Still, suicides are quite rare, and if you have lots of good care documented in the chart in the weeks and months before the event in question that would still count for a lot and might still support that you met standard of care during the encounter in question. So it's kind of a personal call. For me, I prefer having notes entered within 24 hours for a variety of reasons, and I try to keep them succinct.

Oh I agree--but I'm talking about staying late and finishing after clinic instead of typing during the encounter, not postponing documentation beyond the subsequent day--that is poor practice by any measure.

 

[Zenman1]

I'm in an outpatient Army BH clinic. I run off their previous progress note and jot notes directly on it while facing the patient with a clipboard in my hand. If I didn't have their previous note I'd be looking at them like, "You look familiar. What did we do last time?" I dictate right after they leave the room. Here's a one sentence note you can play with.

The patient reports ongoing1 emotional2 problems of moderate3 anger4 starting with the discovery of spousal marital affairs5 two weeks ago6, now does not want to live in the same house7 and associated with disrupted sleep and loss of appetite8.

1. Timing
   
   
2. Location
   
   
3. Severity
   
   
4. Quality
   
   
5. Context
   
   
6. Duration
   
   
7. Modifying Factors
   
   
8. Associated signs/symptoms
   

 

[deleted343839]

What I need to do is finally get set up with our dragon licenses... I'm a very fast typist but I think dictating may still be faster.

I've used Epic with and without integration with Dragon Medical, and the difference is remarkable. You can speak at twice your normal speed and still end up with very few transcription errors. You can also insert smart phrases with dictation, which saves even more time. You'll love it.

 

[PistolPete]

I've used Epic with and without integration with Dragon Medical, and the difference is remarkable. You can speak at twice your normal speed and still end up with very few transcription errors. You can also insert smart phrases with dictation, which saves even more time. You'll love it.

I'd definitely be interested in setting this up for my private practice. Which package do you use? There's multiple different options on Amazon.

 

[AnnoyedByFreud]

I at least partially finish my notes with the patient in the room. At the very least I have the CC/HPI/MSE done. I can type without breaking eye contact from the patient, so it's not really a big deal. I don't really see how it's different from jotting notes on a notepad, since in both cases I'm looking at the patient. This way I often am able to leave ~5-10 minutes after my last patient, assuming I had some no-shows or charted a bit during lunch. I cannot imagine just leaving all my notes for the end of the day.

 

[Merovinge]

I've used Epic with and without integration with Dragon Medical, and the difference is remarkable. You can speak at twice your normal speed and still end up with very few transcription errors. You can also insert smart phrases with dictation, which saves even more time. You'll love it.

Yes this. The best I have ever seen EMRs used is Epic with Dragon. Can save a truckload of time on new evals/consults, I probably save 10+ mins per using that then typing.

 

[deleted343839]

I'd definitely be interested in setting this up for my private practice. Which package do you use? There's multiple different options on Amazon.

It was an institutional license so I'm not exactly sure, but it was some version of Dragon Medical, and I also used the PowerMic tool they sell with it. I've never tried to dictate with the less expensive versions so not sure what the incremental value is.

 

[Jules A]

Yes this. The best I have ever seen EMRs used is Epic with Dragon. Can save a truckload of time on new evals/consults, I probably save 10+ mins per using that then typing.

Love Dragon and have several feeds set up to insert commonly used phrases.

 

[Liquid8]

My current setup is 1 hour intakes and half hour reviews, but because I am obliged to send correspondence back to referring GPs I tend to take fairly detailed notes which is also for my own benefit too. Like others have stated, typing with a patient in the room tends to break rapport, but the problem is unfortunately compounded for me as my handwriting is so abysmal if I don't transcribe or dictate it within the day it can be hard to, uh interpret.

For intakes I’ve been using Dragon which has been a considerable time saving. For reviews it usually takes me about a minute or two to type up if they are straightforward, so I am usually able to finish notes between appointments. I’ve forced myself to limit any written notes to 1 A4 page, and use a format similar to how I was taught as a registrar in community outpatient clinics (New issues, Current meds & side effects, MSE, Impression, Plan).

 

[Ceke2002]

I at least partially finish my notes with the patient in the room. At the very least I have the CC/HPI/MSE done. I can type without breaking eye contact from the patient, so it's not really a big deal. I don't really see how it's different from jotting notes on a notepad, since in both cases I'm looking at the patient. This way I often am able to leave ~5-10 minutes after my last patient, assuming I had some no-shows or charted a bit during lunch. I cannot imagine just leaving all my notes for the end of the day.

Just out of curiosity, what are you actually using to type on? Is it just a standard tablet type thing, or is there a special medical dictation machine you use?

To be honest, although I can't say for certain because I've never had a Psychiatrist appointment/therapy session where hand written notes weren't used, I don't think it would necessarily be the maintenance of eye contact that I'd find to be an issue so much as the experience of physical differences in hand movements and sounds when thinking of someone writing notes by hand compared someone typing those same notes.

 

[Trismegistus4]

I'm revisiting this thread because on the whole, this has continued to get worse for me. I won't say exactly when I left the office today, but it was later than 6:30. Today marked a first in my time here: it was the first time that, for two days in a row, all of my new patients, of which I schedule 4 per day, showed up. So far, the vast majority of days, at least one new patient has no-showed. This made me realize that, as efficient as I can tell myself I'll become, I've still been counting on a certain percentage of no-shows.

Rereading the thread, it seems like the secret is not letting appointments take the full allotted time. Is that right? I vaguely remember, in residency, "hour" long appointments actually being 50 minutes, but because I'm such a pushover, I've gradually lapsed into allowing patients to take the full allotted time. So, should I just start pushing to finish the interview with a few minutes to spare, and kicking the patient out of the room early so I can finish my note? Is that what you guys do? If you spend 50 minutes of a 60 minute appointment with the patient actually in the room, how much do you spend for a half hour appointment? 25 minutes? What do you do when you get behind? In my clinic, we have a policy of seeing follow-ups, which are half-hour slots, as long as they arrive fewer than 10 minutes late. So, if your 2:00 shows up at 2:09, do you still kick them out at 2:25? If not, do you start getting behind? And what about patients who talk your ear off? You know the kind--people who try to answer every simple yes-or-no question by launching into an elaborate story from early childhood, or people who literally will never stop talking, telling a neverending story with absolutely zero pause in the narrative, unless and until you literally start talking over them to interrupt them? There have been times I start pushing to wrap things up at 2:25, launching into the end-of-visit discussion, and it seems like we're going to end on time, only to glance at the time again and see that it's 2:33 and they're droning on again, and when I interrupt them to make my final once-and-for-all statement, they launch into hand-on-the-doornob questions and bringing up new symptoms. Do you just be rude to them and terminate the visit? If not, how do you avoid getting behind?